Doctor Diaries- How do I handle the bias?

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There are people whom we like and then there are those we do not. Knowing somebody up close and personal sometimes magnifies their faults and personality quirks. Now, when we handle such issues in our personal life, there is not much of a problem. There are thousands of quotes on the social media which advice us to stay away from negative influences, so that we can be sunny and positive always. Just stay away and your problems vanish. Clap, clap!

But when you are a doctor, and a psychiatrist at that, a lot of people coming to you are not only distressed but also not “nice”, to put it mildly. Within the first few visits, we know their personalities, their decision making skills and their life choices very closely. As a matter of rule, we need to be at our non judgmental best in our counseling. Allow the person to make his/her own life decisions. At best, we can steer them towards a choice, but that too, very unobtrusively.

Unfortunately, this seems utopian on paper, not reality. How can one remain unaffected when he/she hears of a man boasting of knowing how to keep his unruly wife in place by resorting to violent means? How do you react when a lady comes depressed because she is worried about her daughter in law being snubbed by her own daughters? Such a concerned woman, you think. The concern emerges from the fact that the girl’s father has paid a fat dowry and is asking uncomfortable questions about the same! How do you console a father when he cries, that we should convince his daughter to go back to her alcoholic husband’s home, because they have already depleted their life savings on the marriage? How do you convince an utterly melancholic woman (melancholic because, her parents had no male progeny, and hence died uncared for and now the daughter in law has produced two healthy bonny girl babies), who obviously will leave her uncared for too?

These are situations which arise frequently. On a particular level, I understand that these are people who have a different value system and a way of thinking alien to mine. They may have a genuinely good side to them and maybe just discussing their miseries. Atleast they are honestly bad! But these are also times which make me want to quit my “non judgmental” high horse and tick them off like a very strict school marm.

I keep squirming in my seat trying to calm the feminist in me. Most times, I am successful. Occasionally, my unobtrusive push becomes slightly more forceful. And rarely, I do scold. I do fervently hope, that  this happens to anyone who handles human emotions as a part of their profession.

We do not understand the decisions that others make and their reasons for it. Over the years and with some maturity comes the discovery that we cannot change the world so easily. Change is for most part slow, a lot of hard work and painstaking. Once the abusive husband, after 6 months of counseling, finally stops abusing his wife physically (though a wee bit of verbal abuse remains), I should consider it my victory!

Unfortunately, this victory is not all sweet! There is an itch to do something more, push a little more and dream a little. And go back to listening all over again. Maybe, this is more like the bevu bella (an offering of neem and sugar eaten during ugadi, the traditional new year), which symbolically signifies that you should swallow the good and the bad with equanimity. Probably, I should start everyday with a small bite of the same:)

Does this happen to you?

 

 

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Doctor diaries – English Vinglish in the hospital.

 

wrong english
Ha, ha note what is tasted here!

Though the English left India 70 years ago, their language and its symbolization as superior and powerful has continued. It is a rare parent who does not beam with joy when his child speaks some English. Parents make sure they scrape their hard earned money to put their child through an English medium (which means elite in other words) school. Schools charge their students a fine if they are caught speaking their mother tongue on campus. Even parents of special children who come to my consultation room, coax their kids to “Say” in English, the answer to any question that I ask in kannada.

A knowledge of English is seen somewhat as a sign of superiority, a matter of pride and a way out of future poverty. Phew! So much burden for one language to carry! And I am sure that if English were a person, she would have crumbled under this intense pressure (which is probably more than what P.V.Sindhu faced on the eve of her final match at Rio) of millions of Indian parents for long long years. She would have probably scooted the country far before the British did. But she did not. And here we are –grappling with realities.

I love the fact that we live in a country with so many languages. Each language with its own flavor and essence. English, I love –because I studied in it for most part and knowing it, helped me expand my horizons. Kannada because it is the language of my land. I enjoy the strangeness of my mother tongue Konkani. I love the way Tamil and Marathi sound. Hindi seems to me, a way to understand tv, my North Indian patients and our prime minister’s ‘Man ki baat’! Though I worry about landing with a twisted tongue, I did learn quite a few sentences of Malayalam! I love the fact that we are a language potpourri. English words which have been Indianised and used ever so casually with an air of ownership. My daughter and son believe that “bussu”, “caru”, “traffic jamu” “hotelu” are essentially kannada!

So, it is not that I have anything against the language. I am not a language fanatic nor a grammar nazi.  Nor am I a snob who believes that people who speak english incorrectly are imbeciles. I understand that it comes from learning with limited means and lack of practice. But I believe in people knowing their limitations. That they are fluent in a few languages and have to treat the others with caution. Or if they did want to use it conversationally, it would happen with hard work rather than over confidence.

Well, that does not seem to be the case with our poor English. Apart from being put on the podium as a status symbol, she is also tortured continuously and most times hilariously. A lot of it which I get to see in my hospital.

Starting from my internship.  Along with my co intern, I had spent the night filling in patient information into files, when the hospital attendant announced that the head nurse wanted the “cassettes”. We looked back blank. “Which cassettes?”.  “The ones you are filling.” Realization dawned. He meant the “case sheets”.

Or when the duty nurse sent me a note from the far flung recesses of the TB ward. The note read “Doctor, the patient in ward 9 has not passed urine or stools since two days. Please come and pass it”.

When in my residency, we were posted in a  Government hospital whose cassette, sorry case sheet carried a mandatory question of finding out why the patient had landed in that particular hospital for treatment. Most patients would reply that they had come over for free “statement”-meaning “treatment”. “Please give my son good statement”, they would ask of us. And after the free statement was given, they would profusely say “TANK you” and leave us sufficiently tanked in their wake!

Once I started my practice, I realized the all encompassing power of the word “aunty”. There was once this eighty year old man who called me ‘aunty’ at the end of Each. And. Every. Sentence. Which was promptly followed up by his obedient wife, who was almost seventy and had only one single tobacco stained tooth in her mouth. The auntying got so severe that I caught myself unconsciously smoothing my hair to cover my grey strands for the next one hour!

The best was yet to come. There was once a concerned husband who hovered around after I finished counselling his wife. He then came over and whispered conspirationally,  “Madam, can my wife try property?”.

I thought that he wanted to be sure that his depressed wife was lucid enough to make decisions about her finances and real estate.”Sure, no harm”, I replied. “She is smart enough to handle and plan her finances”.

He did not seem convinced. “But property?”, he insisted.

Now, this instantly made me suspicious. I wondered whether he was planning to cheat her and do away with her money.

“Why exactly are you asking me this?”, I  queried.

He must have caught my tone of irritation.”Madam, I care about my wife and her health. We wanted to be sure to have a gap of three years between our kids”.

Now, I was confused. Family planning and real estate. No bells rang. I finally asked him to explain what exactly he meant.

He looked at me rather pityingly, at my lack of common medical knowledge. “Madam, you know that thing they use nowadays to prevent pregnancy-they insert it into the uterus- it is called property. Never mind. I will ask my wife’s gynecologist about it”

Turns out he meant “copper T”.

I rest my case.

 

Learn yourself English.

Do-No-Harm

We doctors, are suspended in a strange state of limbo. Gone are the days when consultants treated patients like minions who had to accept their judgment without questions. Also are bygone the days, when concoctions from bottles of various sizes were mixed together and passed on as panaceas for all ailments.  The compounder who would dutifully carry the doctor’s bag and keep the clinic running like clockwork is also, now an extinct species.

We are now in an era where hospitals are treated like business with business models, plans, huge glassed buildings and air conditioned offices. The targets they have to meet to get such a huge gargantuan venture going, loom large in front of the doctors.

The reason we are in a limbo is probably this- that at heart we are still pompous old world people who believe in our skills and dealing with a patient who does not believe in it brings us crashing down to reality!

A lot of patients now behave as though they have come to a hospital for a business transaction. They give us money and we give them health. When the deal works well, everything is hunky dory, but when things go awry, the doctor bears the brunt of it. And how. He is beaten up, the hospital is ransacked and the staff are manhandled, before the good old police finally reach the scene.

In such a scenario, it is not strange that doctors develop a defensive attitude of not accepting our mistakes. And mistakes do happen. After all we are humans. Only, we deal with other humans!

Though treatment procedures have been standardized for years, first in the lab, then on hapless animals and then tried on humans to prevent any mishaps, we know that patients react differently to different drugs. At least 1 in 10 patients and their illness does not behave as obediently as we expect. According to a study in Australia, about 18000 deaths occur in a year due to medical errors! A lot of times the body plays tricks on us. Placing red herrings, leading us on a merry path to a destination, which is exactly at the opposite end of where we want to be. We have to start afresh then. Slightly more cautious and worried. And rarely, it does happen that we mess up bad. And it does end in the patient’s demise. A valuable but a very sad lesson.

Unfortunately, in our profession, accepting our mistake is taken as a sure fire sign of guilt. We only have the freedom to accept our mistakes when we are doing our residency, when the worst we have to face for this is the wrath of our teacher.

Therefore, when I read “Do No Harm”, by Henry Marsh, a neuro surgeon from Britain, I enjoyed it immensely.

First, because it acknowledges that we as doctors are human and need to get it into our head that failures do happen. He has portrayed himself as genuinely as possible. That, at times, he is guilty of losing his temper, sometimes his decisions have been made by how tired he was or how the weather was behaving! This admission according to me, was extraordinarily brave. l have made some purely selfish decisions, but till date ,have great difficulty in acknowledging it! It is always easier to defend myself. And hence, the greatness of this man, who has actually put it on paper.

Secondly, the book also gives us examples of the times when things do not go as expected. The moral being- catharte, accept, console, move on- but do not forget for next time!

Thirdly, that vice versa can also happen. Those whom we expect the worst to happen, go on to outlive their children and we end up being at the end of condescending glares and living room gossip. So to learn to communicate the truth, but not to give out ultimatums. Instead, to be gentle and as hopeful as possible.

Lastly, but most importantly, the book gives us insights about knowing when to stop our work and accept that nature has to take its course. As doctors we sometimes get carried away by the drama of keeping the patient alive by all means. But the consequences of such survival may be more of a burden than help. Like when the operation is a success, but the patient ends up in coma for years. The relatives are at a loss financially, emotionally and unable to take a decision about the future!

Do no harm is a book which deals with such difficult questions and circumstances which every doctor faces but is unable to voice out. It is honest, upsetting sometimes, but definitely re assuring for two reasons.

One because, it gives a sense of solace that the dilemmas shared by doctors all over, are not unique.

Two, because come what may, being honest with the patient and family, brings alive a bond akin to what was present eons ago- a sense of understanding, and a trust level which allows for acceptance even if we inadvertently harm their dear ones.

How I wish this book was a part of my medical school reading!

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Are we treating the right person??

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Doctor Diaries….

Each department of medicine has its own challenges. If it is long tedious hours in emergency medicine, the unexpectedness in surgery or obstetrics, or the sense of futility which sometimes goes with oncology, I feel that in general, doctors have these “times” where you really start to wonder whether you are doing the right thing!

There are many such unique challenges which belong to the realm of psychiatry, when as a consultant, you feel as if you are bound by some invisible shackles which prevent you from doing the best for your patient.

Mental illhealth has always been considered with suspicion, even by some of the most intelligent brains in the world, mainly because of its slippery definitions. Also because of the fact that there are no diagnostic tests which can surely classify a patient as mentally ill. Other than the obviously aggressive or flagrantly abnormal patient, most times,  we need to tease out the the history from many of their kith and kin to arrive at a diagnosis by circumstantial evidence aka Sherlock Holmes!

And when we do so, many a times, we end up realizing that we may be, cut that, we ARE trying to treat the wrong person!

Let me elucidate…

Take the case of a woman who has been referred because of a near lethal attempt at deliberate self harm( which is just a fancy name for attempted suicide). The woman, on enquiry, confesses that she is tired of her life, and one of the main cause is the unnecessary amount of suspicion which the husband has developed, in part because of his alcohol habit. He does not allow her to talk with her friends, has made her give up the job she loved and beats her up when intoxicated. Her maternal family, expectedly tells her that she has to “adjust”. So here she is.

Take another example of a child who is sullen, angry and puts zero efforts into his study. The father who is a teacher explains that his son is so ‘dumb’ that he needs to be spanked everyday before he sits down to do his homework. He also explains that he gets so frustrated with his son that, on occasion, he has branded him with a hot iron for his follies. The son was diagnosed to be having learning disability.

In another case, the son who has been a patient of childhood schizophrenia gently chides his mother, who has accompanied him, not to interrupt me multiple times before I complete even one sentence of what I say. “Calm down, Ma” he says and looks at me resignedly. He has probably experienced this phenomena all his childhood, and I can pity him, for I am already exhausted by her!

Such situations are tricky.

If I go on the offensive and tell the relative that he or she is the one who actually needs help, they may dissappear with the patient and never turn up again! Such are the follies of a stubborn ego. Intent on proving the other person wrong and unconsiously expecting some praise for an apparent  sacrifice which has largely gone unappreciated.In the process, I lose out on helping a person who genuinely needs the help which I am qualified to give. Granted it may not completely cure him, but atleast I can lend a much needed listening ear and psychological balm.

On the contrary,when  I  go with the version given by the relative, and reach for my prescription pad, immediately, I see a look of betrayal in my patient’s eye. “Et tu, doc” it seems to say, “I knew no one would understand”. I feel so uncomfortable when I see this look. As though I have let him down badly.

So what we do is, to talk to both of them separately; tell both of them that we understand their point of view, and other’s mistake; and promise to help as much as we can! Sounds devious?? It does,but it also is the most honest answer, according to me.

It works quite a few times, mainly because, as  people, we have real fragile egos. If someone tells us outright,that we are wrong, we suddenly become extra defensive .It takes gentle prodding and many sessions of talking for them to grudgingly accept the fact that they may have played a part in making their dear one sick! Then, we have struck gold! They are amneable to suggestion, and if necessary, medication.And slowly we begin to see a steady improvement in the patient’s condition.

But, ever so often, this does not happen. Despite subtle suggestions, followed by obvious ones, some refuse to change. And sometimes become worse, for they miscontrue that the patient has complained about them. And the patient’s eyes steadily lose their lustre.

I know that we are human, and we can only win some and etc. etc., but each time I write out a presciption for a patient who is so, because of someone else, I still cringe a little at the unfairness of it all.

Why are we treating the wrong person???

Have any of you encountered such situations?

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A little bit of empathy- Doctor diaries.

 

Monotony brings in boredom. I believe that this happens to the best of us, in whichever profession we happen to be involved in, and so medicine is no exception. Though we start of as idealistic, bright eyed, young doctors, over the years, we get jaded due to tiredness and the sheer numbers that we treat. There is hardly any time to think. Rather, we work more by force of habit, than the passion that we started of with.

Prof. B.M. Hegde, the former Vice Chancellor of MAHE University was often known to quote, that as doctors, we need to cure rarely, care often and comfort always.  But in the mad juggle of life, responsibilities and work, we sometimes lose out on the sensitivity which we need to show the patient, rather than just treating him.

As a mental health professional, the number of times that I have had to diagnose a life threatening illness is less as compared to many other branches of medicine. Rather, most of the illnesses in my bag, fall in the category of life altering. Nothing remains the same after the diagnosis is made. Both for the patient and the family. A lot of times, this causes morbidity in ways which are unseen, but cause a lot of suffering. Decisions that fall outside realm of medicine, like long term medications to be given to patients who are not so willing to swallow them, the crashing of dreams which the parents would have built for their children, the change in roles and responsibilities when the bread winner of the family falls sick, the insecurity of a relapse, the frustrations of the family which work adversely on patient outcome and the societal shaming – all of which are invisible to us, but very much a part and parcel of the illness. And as it is invisible, it often becomes easy to brush off conveniently under the carpet.

It was on one of such days when I diagnosed schizophrenia in a seventeen year old boy. The mother  broke down and started crying copiously. After customarily consoling her, I happened to remark that there were others who had worse forms of the disease, and so should consider herself lucky. To which she replied that maybe it was so, but she was crying not only for her son, but also for breakdown of her life which was painstakingly constructed for the past so many years. She told me that she had to cry so that she could grieve the loss, the burden and her son, and only then she could accept it. She asked for permission to cry, because she could not do it in front of her son or family. Once done, she walked away quietly, only to return for the next visit with a set of questions regarding how her son and family could cope better.

This small incident made me rethink my qualities as an effective counselor. As a doctor, I had thought it important to treat the disease, but forgot about the patient and his family. I could have consoled myself saying that the lack of time was the cause of this heartlessness, but it somehow seemed unforgivable. There are many instances that I have seen, where there are doctors with no super specialty degrees or  swanky clinics, but where the Que for visiting the doctor is serpentine. What they call “Kai guna” in kannada, must be the magic of sharp observation, unhurried questioning and a profound sense of empathy used together as treatment. This combination must be more potent than all the medications and hi fi equipment put together.

From then on, I resolved to spend a little more time with my patients than just enough to spot the diagnosis. And the results have been nothing short of remarkable. Now I have extended families in my patients. The caretakers know that they have a shoulder to cry on and are hence more comfortable. Each milestone they have achieved becomes partly mine. And when the seventeen year old passed his class twelve with a first class, I got home a huge box of yummy mysurpak. There seems to be no monotony anymore.

Doctor Diaries.

There are certain life experiences which come to us, courtesy our professions. Some of them make good dinner table conversations, some put a smile on our face years after they occur and some make us feel a deep pain inside. As doctors,  we see many incidents which have the power to move us beyond what we thought was possible. And such incidents make us richer, wiser and sometimes more cautious. I have always wanted to share a few of my experiences as a doctor first, a psychiatrist next, about how we see the good, the bad, the ugly and the hilarious as a part of our everyday life in the hospital. Hence ,the doctor diaries.

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Of when my idealism died.

Off late, medical professionals  have been viewed more with suspicion and wariness than respect and love. We often hear stories about how doctor so and so ripped off a poor patient, or performed an unnecessary surgery or followed some unethical practice.

As much as I know of most people in our profession, they seem hard working to such an extent that they have no time to even defend themselves in times of crisis. In a day and age, where most media bytes  go to a person who voices the highest decibel levels, we seem to have missed the bus by a mile. A lot of us are excellent clinicians, but poor communicators. Mostly, not our fault. We were never taught that our practice, would one day, turn out to be a war zone with land mines, which we had to gingerly tread through. Do not get me wrong. It is not everyday that we go to work like scared rabbits. We enjoy what we do, and how we do it. But on occasion, fear does seep into our bones. This was one such time.

It was a sleepy Sunday afternoon broken by an earth shattering cry, that would have woken the dead. All of us in the surrounding vicinity came out on the roads to see what had happened. What we saw was not a pretty sight. There were two people who had accidentally got electrocuted, lying on the road literally fuming at the mouth. There was this huge crowd gathered around. The stench of burnt flesh was overpowering. I live just across from the hospital that I work in. By the time I made my way through the crowd, I saw that two of our hospital staff had already lifted the victims bodily,and put them into an auto rickshaw.They drove on to a tertiary care center five minutes away for ICU care. The whole episode must have taken around five to seven minutes at most. I was impressed by the immediate action taken by our orderlies and was on my way to praise them, when I was in for a rude shock.

One of the people from the crowd asked us why we had not taken care of the patient. They started accusing us of poor first aid. We appeared confused at first. They must have taken it as a sign of weakness or guilt.

The cause for our confusion, was the fact that, apart from having a time machine to do the needful, we had been as fast as we humanly could. Two of our staff had rushed to find autos on a deserted road to ferry the patients, while two others had helped them into the vehicle and gone to the hospital with them. According to us, we had done all we could and more.Apparently not.

According to the leader of the mob, we needed to check the pulse of the patient before we put him into the auto. The other claimed that we should have done first aid inside our hospital premises before shifting him to an ICU.

We tried reasoning out that time was of utmost importance. That there was no need to check the pulse when the patient looked alive and was breathing. And we shifted him to a tertiary care center only because we did not, as a facility catering to mental illness, have an ICU facility and ventilator support.

Seemingly, all our explanations fell on deaf ears. The crowd kept chanting that we should have checked the pulse. On one level, I knew that they were just out to create a scene. Maybe the shock of seeing a person burn was too much to take. Maybe, they had no idea what to do in case of such a situation.

But on another level, we were scared. Upset that our good intentions were being slandered unnecessarily. Scared that they may abuse us physically.Are really really worried as to why understanding such a simple explanation seemed impossible to them.

Anyway, after a while, for lack of any other logical form of argument apart from the “pulse”, the crowd dispersed. But the hurt remained. That we, (especially our hospital staff who courageously helped the victims without a thought that they may have got electrocuted themselves too) were considered villains even after selflessly doing our best.

It did not matter that half the crowd was totally drunk, and had not moved a muscle to help all through the episode.What did matter, was that a scene was created. And that we looked like the bad people.

In the pat two years, in the small city that I live in, I have seen at least  four hospitals getting ransacked and damaged for some alleged negligence on the part of a doctor, which has later on been disproved. I have participated in rallies held to protect the rights of doctors. The district administration has given us a list of laws and provisions to help us protect ourselves. We now have cctv’s in our hospitals.Despite all of these, the sense of disillusionment remains.

Sort of like, when you have actually done your homework, but forgotten the book at home. The teacher does not believe you, but you want to be believed oh so badly. Standing in front of the class looking like the culprit pains you bad. The pain, that neither your teacher or your friends had the good sense to believe you.Submitting the homework book next day does not really ease your pain. The damage has been done!

And so also in this case.Life  moved on. Work resumed the next day. But every time I pass by the place on the road, I feel a physical pain deep inside me. One for the victim, who was a young man with small children. Two, for my idealism, which died a more cruel death that day.